Download E3 Lec 14 Eating Disorders

OS 211 [A]: Integration, Coordination and Behavior
Lec 14: Eating Disorders
January 13, 2014
Rosanna De Guzman, MD
TOPIC OUTLINE
I. Eating Disorder
II. Anorexia Nervosa
III. Bulimia Nervosa
IV. Binge Eating
V. Conclusion
I. EATING DISORDER
A. OVERVIEW



Eating disorders involve a series of disturbances in eating
behavior, such as extreme and unhealthy reduction of food
intake or severe overeating, as well as feeling of distress or
extreme concern about shape and weight.
Interactions of the following factors may lead to eating disorders:
o Biology
o Family
o Social/cultural messages
o Individual characteristics
o External/situational stressors
o Behaviors and their consequences
o Power struggle with others
Eating disorders related to reduction of food intake are not
common in the Philippines because Filipinos love to eat.
(Not included in the lecture)
From 2016 trans:

In other countries (USA, Australia), there are special
hospitals that address eating disorders.

Eating disorders are associated with suicide.

Common in adolescents (specially women) which may
result in them abusing themselves through induced
vomiting, excessive exercise or use of pills (ex. Bangkok
pill)and laxatives.

Becomes more difficult to treat with increasing age.
*Bangkok pill- may cause severe paranoia and other
temperamental problems.
FACTS

80% of women who answered a People magazine survey
responded that images of women on television and in the
movies make them feel insecure.

A study asked children to assign attractiveness values to
pictures of children with various disabilities. The participants
rated children with disabilities as more attractive than obese
children.

The average US woman is 5’4” and weighs 140 lbs.

The average US model is 5’11” and weighs 117 lbs.

A study found that adolescent girls were more afraid of gaining
weight than getting cancer, nuclear war, or losing their parents.

Bulimia can cause damage to the reproductive system, kidney
failure, cardiac arrest, and ulcers of the intestinal tract.

Many people with eating disorders are addicted to exercise.

The average life duration for people with anorexia is 1.7 years,
with bulimia is 8.3 years, and those with binge eating is 8.1
years.

Bulimia nervosa and binge eating are very common in white
women.

Eating disorders are common for 10-14 year olds, until the age
of 24, and the disorders can last up to 10 years.

Searching about eating disorders was done in different ways:
o Searching through the internet:

Agencies

Arbitrates magazines

Books

Popular magazines
o Searching through the library catalog:
Bea Phonse Thea
3
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Through books, magazines, thesis and periodicals
in the circulation area, reserved area, and
computer area.
AMERICAN PSYCHIATRIC ASSOC. PRACTICE GUIDELINE FOR THE
TREATMENT OF EATING DISORDERS (3rd ed, 2006)

Amenorrhea is not eenough to diagnose anorexia nervosa.

“Atypical” anorexia nervosa may have better prognosis because
of willingness to change.

Assess motivational stage, interpersonal attachment, and the
overall attachment to life.

Treatment of anorexia nervosa is related to the intensity of the
disorder.

NG tube feedings for anorexia nervosa value.

Family therapy (separated or conjoint) and psycho-education
are important.

For Osteoporosis: nutritional rehabilitation assuring sufficient
protein, carbohydrates, fats, calcium and vitamin D is essential.

For Bulimia: DBT > CBT > NT > Support.

Fluoxetine is given even for patients who fail CBT.
DEFINITIONS

Eating disorders include anorexia nervosa, bulimia nervosa,
anorexic and bulimic behaviors, unhealthy dieting practices,
binge eating disorder and obesity.

Anorexia nervosa is self starvation; in which preoccupation with
dieting and thinness leads to excessive weight loss. One may die
of severe starvation and dehydration. Ex. Karen Carpenter and
Miley Cyrus

Bulimia nervosa is the recurrent episodes of binge eating an
excessive amount of food within a discrete period of time and by
a sense of lack of control over eating during the episode. Ex. The
late princess Diana

Binge eating disorder is ingesting an unusually large amount of
food very fast while feeling out of control over the eating
episode. The person usually denies that she does binge eating
secretly.

Anorexic and bulimic behaviors are undue influence of body
weight or shape on self evaluation, or denial of the seriousness
of the current low body weight < 15% of normal BMI; self
induced vomiting or misuse of laxatives, diuretics, enemas, or
others; fasting; excessive exercise.

Obesity means having an abnormally high proportion of body
fat.

Unhealthy dieting practices is such as restrictive dieting.
Figure 1. Eating Disorders
Not Otherwise Specified
(EDNOS) Diagram

Higher prevalence
of bulimia nervosa than
anorexia nervosa in the
general population.

Eating disorders
are underreported because
many think they don’t have
a problem
EATING DISORDERS

Eating is controlled by many factors, including appetite, food
availability, family, peer, and cultural practices, and attempts at
voluntary control.

Eating Disorders are serious and complex emotional and physical
addictions.

Without treatment eating disorders lead to mood swings,
physical problems, and potential death.
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Lec 14: Eating Disorders

Include a range of conditions that involve an obsession with
food, weight and appearance to the degree that a person's
heath, relationships and daily activities are adversely affected.

Characterized by severe disturbances in eating behavior.
They become delusional and unresponsive to medications because it
is considered as a behavioral problem.
B. CATEGORIES OF FACTORS THAT LEAD TO EATING DISORDERS
BIOLOGICAL RISK FACTORS
 Eating Specific Factors (direct risk factors):
o
Eating specific generic risk
o
Physiognomy and body weight
o
Appetite regulation
o
Energy metabolism
o
Gender (women are more prone to eating disorders)
 Generalized Factors (indirect risk factors):
o
Genetic risk for associated disturbances
o
Temperament
o
Impulsivity
o
Neurobiology (occurrence of mood disturbances)
o
Gender
PSYCHOLOGICAL RISK FACTORS
 Eating Specific Factors (direct risk factors):
o
Poor body image
o
Maladaptive eating attitudes
o
Maladaptive weight beliefs
o
Specific values or meanings assigned to food and body
o
Overvaluation of appearance
 Generalized Factors (indirect risk factors):
o
Poor self image (low self-esteem)
o
Inadequate coping mechanisms – undue compliance
o
Self regulation problems – extreme perfectionisms
o
Unresolved conflicts, deficits, posttraumatic reactions
o
Identity problems – regression to childhood and an escape
from emotional problems of adolescence
o
Autonomy problems
From 2015 trans:
 Emotional Causes of Eating Disorders. The National Institute of
Diabetes and Digestive and Kidney Diseases (NIDDK) suggested a
relationship between binge eating and emotions that binge eaters
are not adept at handling. People who bingeeat may identify
particular emotions - including anger, sorrow, boredom, and
worry - that can lead them to binge.
 Psychological Causes of Eating Disorders. Depression is often
associated with binge eating disorder, >half of patients have a
history of major depression.
 Interpersonal Causes of Eating Disorders. NEDA (National Eating
Disorder Association) identifies interpersonal factors that can
contribute to eating disorders, including a history of problematic
family or personal relationships, trouble expressing emotions, and
a history of either physical or sexual abuse
 Recent studies show that Anorexia nervosa and Bulimia nervosa
are linked to Obsessive-Compulsive disorder
DEVELOPMENTAL RISK FACTORS
 Eating Specific Factors (direct risk factors):
o
Identifications with body concerned relatives, or peers
o
Aversive mealtime experience
o
Trauma affecting bodily experience
 Generalized Factors (indirect risk factors):
o
Overprotection
o
Neglect
o
Felt rejection, criticism
o
Traumata
o
Object relationships (interpersonal experience)
SOCIAL RISK FACTORS
 Eating Specific Factors (direct risk factors):
o
Maladaptive family attitudes to eating and weight
Bea, Phonse, Thea
OS 211
o
o
o
o
Peer group weight concerns
Pressures to be thin
Body relevant insults and teasing
Specific pressures to control weight (through ballet, athletic,
pursuits)
o
Maladaptive cultural values assigned to body
 Generalized Factors (indirect risk factors):
o
Family dysfunction – disturbed relationships
o
Aversive peer experiences – rigidity and lack of conflict
resolution
o
Social values detrimental to stable, positive self image
o
Values assigned to gender
o
Social isolation – due to over protectiveness
o
Poor support network
o
Impediments to means of self definition
From 2015 trans:
 Social/cultural Causes of Eating Disorders. Media images present
an ideal image of women that are farther from the average
woman's body. The Social Issues Research Centre (SIRC) reports
that in 1972, the ideal woman shown in the media (models, movie
stars, etc.) weighed less than the average woman, but only by 8%.
By the late 90s, the difference had become 23%.
 Constantly seeing an ideal that is so far from one's own reality can
create a sense of pressure and lead to unnecessary dieting and
possibly to eating disorder (according to The Eating Disorders
Association in England). In fact, distorted body image is a defining
characteristic of anorexia nervosa. Thus, treating eating disorders
does not simply involve helping people learn to make healthy
choices about nutrition, but also involves helping change how they
perceive themselves so that their view becomes more realistic
C. OBESITY RISKS

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High blood pressure
Stroke
Cardiovascular disease
Gallbladder disease
Diabetes
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Stunted growth
Delayed menstruation
Damage to vital organs such as the heart and brain
Nutritional deficiencies, including starvation
Cardiac arrest
Emotional problems such as depression and anxiety
Respiratory problems
Arthritis
Cancer
Emotional problems such as
depression and anxiety
D. OVERALL HEALTH RISK FACTORS
II. ANOREXIA NERVOSA
2 Year old self-portrait:
1) Library: 5 Minute Exercises, Recipes
for Health, Calories Do Count, Secrets of
Staying Thin
2) Exercise rope
3) Clock always at mealtime
4) Plate with vegetables, fruit, no meat
or fat. Most food uneaten
5) Forbidden foods beyond arm’s reach
6) Externally: Superwoman
7) Internally: An empty skeleton.
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Pursuit of thinness
Insufficient energy intake
Wasting of the body
Delusion of being fat

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Obsession to be thinner
Does not diminish with
weight loss `
Denial`
A. ANOREXIA DIAGNOSTIC CRITERIA

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Low body weight (<15% of BMI)
Extreme concern about weight and shape characterized by
intense fear of gaining weight and becoming fat .
Strong desire to be thin
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Lec 14: Eating Disorders


In women, amenorrhea
Be sure to include weight in the physical examination and
compute BMI and ideal body weight.
o

B. SIGNS AND SYMPTOMS
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Refusal to sustain a minimally normal body weight
Intense fear of gaining weight, despite being underweight
Distorted view of one’s body or weight, or denial of the dangers of
one’s low weight. They overestimate their own size (Experiment:
an open door in the shadows: patients think they can’t fit).
Insufficient energy intake and wasting of the body.
Delusion of being fat and obsession to be thinner.
Does not diminish with weight loss.
Denial.

Return of menses is related to gain of lean and fat body
mass
Musculoskeletal changes
o
Reduced skeletal muscle mass
o
Causes of osteopenia/ osteoporosis
o
Low weight
o
Ineffective load-bearing exercise
o
Low estrogen, High cortisol
Others
o
Edema, slow capillary refill, acrocyanosis, caroetmia
o
Livedo Reticularis

Bluish discoloration of the skin

Reticular (“lacy”) pattern
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Asymptomatic, but often associated with low core
temperature and metabolism.
C. MEDICAL CONSEQUENCES
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Anorexia nervosa starves the body of the essential nutrients it
needs to function. To conserve energy and the small amount of
nutrients available, the body's processes will slow down. This
"slowing down” can have grave medical consequences, including:
o
An abnormally low blood pressure and slow heart rate
caused by weakening heart muscles. This increases the risk
for heart failure.
o
Muscle loss and weakness,
o
Due to hormonal abnormalities: Osteoporosis. Reduced
bone density cause dry and brittle bones prone to breakage.
Secondary to starvation:
o
Severe dehydration, which may result in kidney failure.
o
Fatigue, fainting spells and weakness.
o
Lanugos, a downy layer of hair that appears all over the
body including the face in an effort to keep the body warm.
o
Dry skin and hair. Hair loss. Hormonal abnormalities.
Dental Enamel Erosion
o
Erosion of enamel (white) and dentin (yellow) from
persistent vomiting, resulting in tooth decay and fracture.
o
Worse on lingual than buccal surfaces.
Malnutrition and hypometabolism
o
↓ Energy intake results in wasting of lean muscle = ↑fat
o
Metabolism occurs in the lean body mass
o
Energy conservation: ↓BMR, ↓Temp, ↓HR, ↓Peripheral
blood flow, ↓Physical activity.
o
~70% of regained weight is lean body mass.
Cardiovascular: physiologic vs. pathologic
o
Physiologic:

Bradycardia (↓energy intake)

Cold hands/feet (energy conservation)
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Slow capillary refill (low cardiac output)
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Acrocyanosis (deoxygenated hgb)

Orthostatic
pulse
change
>25
bpm
(compensatory)
o
Pathologic:

ECG: non-specific changes (voltage ↓, R QRS axis,
ST ↓, T flat or inverted, U waves)

Echo: normal contractility
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Dysrhythmia: ventricular tachyarrhythmia

Surveillance depends on findings and symptoms
o
Symptoms respond to adequate nutrition. Adequate energy
intake is needed to gain weight. Moderate exercise after
intake exceeds output and limit exercise if possible.
Gynecologic changes
o
Amenorrhea and infertility (related to weight and exercise)
o
Menstrual weight: ~90% ABW for height
o
Prolonged amenorrhea does not preclude childbearing
o
With adequate weight gain, fertility returns to normal (but
ovulation weight may exceed menstrual weight)
o
Birth control pills preclude using menses as a sign of
physical health recovery. Pills (and other hormonal therapy)
result in withdrawal bleeding, NOT MENSES.
o
Progesterone challenge does not kickstart normal menses
Bea, Phonse, Thea
OS 211
D. COURSE AND PROGNOSIS
o
o
o
o
o
Fluctuating course with exacerbations and remissions
It takes a chronic course with recovery after many years
Weight and menstrual function may improve, but eating
habits often remain abnormal
Predictive factors: length of illness at presentation and age
of onset
The younger the age of onset, the more difficult to treat
because it becomes ingrained with the way they live.
CAVEATS IN PRIMARY CARE

Negative:
o “Classic” presentation less likely in younger patients
and/or shorter duration of illness.
o No single “cause to this final common pathway.
o No diagnostic lab studies
o Opinions are less important than facts
o Initial goal is not to diagnose an eating disorder, but to
determine the cause of weight loss

Positive:
o Physical findings are a result of weight control habits
o Mental status is part of the physical examination
o Laboratory studies for baseline, or to reinforce physical
examination finding
o Motivational interviewing avoids many pitfalls in
management
o Parents are part of the solution to the eating disorder
DIAGNOSTIC ALGORITHM FOR WEIGHT LOSS

Is weight loss intentional and/or desired?
o Unrecognized illness
o Increased energy needs due to exercise or growth
o Efforts to “get in shape”
o Energy restriction (intake) or output (exercise)

Excessive dieting or exercise
o Symptoms, signs, body image distortion

Pursuit of thinness/avoidance of obesity is the major issue
o “Healthy” habits directed toward sport, dance, etc
o Unhealthy habits

Determine the level of care needed
o Outpatient/ Intensive outpatient
o Partial hospitalization
o Inpatient/ residential
E. TREATMENT

Treatment of anorexia calls for a specific program that involves
three main phases:
o
Restoring weight lost to severe dieting and purging. After
restoring weight lost psychotropic medication is used.
o
Treatment of psychological disturbances such as distortion
of body image, low self esteem, and interpersonal conflicts
o
Achieving long term remission and rehabilitation, or full
recovery
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Lec 14: Eating Disorders
INDICATIONS FOR HOSPITALIZATION

> 75% of predicted body weight

Inability to eat.

Changes in blood pressure, pulse, temperature are
indicative of seriously compromised circulation and
organ perfusion.

Cardiac arrhythmias
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Serious serum electrolyte abnormalities: potassium,
phosphorus, sodium

Esophageal tears

Intractable vomiting

Failure to improve despite intensive outpatient
treatment

Psychiatric instability: danger to self/others (ex. Suicide)
ENGAGING PARENTS IN TREATMENT

Developmental framework (child  adult)
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Discuss the blame, fault, and guilt openly

Realignment of roles in the family
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Positive framing of family attributes

Future orientation

Authority to treat and empowerment of professionals
come from the parents
PROBLEMS ADDRESSED IN MENTAL HEALTH TREATMENT

Low self-esteem

Distorted body-image

Dysfunctional coping behaviors and habits

Depression (SSRIs (selective serotonin reuptake
inhibitor) only for bulimia nervosa or weight recovered
anorexia nervosa)

Ineffective communication

Conflict resolution

Lack of assertiveness

Post-trauma recovery (sexual absuse, etc).
IV. BINGE EATING
A. SIGNS AND SYMPTOMS
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Rapid weight gain.
Eating large quantities of food even when not hungry
Disgust and shame after overeating.
Depressed and anxious mood.
Eating food to the point that one is uncomfortable (in pain)
Going from one diet to the next constantly
Feeling out of control over food
Eating late at night
Hiding food around the home, anticipating a binge
Does not use any measures to purge the binged food
Constant weight fluctuations
Sexual avoidance
Exhibits an abnormally low self-esteem
Attributes any successes or failures to weight
Avoids many social situations

First steps in treatment: DETOX. Get rid of high sugar and refined
flour food diet.
Detox medications to ease mood swings and discomfort during
the treatment process.
Upon completion of detox, individualized treatment begins. A
nutritionist designs a healthy eating plan for each patient.
After implementation of treatment plan, each patient will then
participate in a variety of clinical activities focused on addressing
the root cause of their binge eating.
B. TREATMENT



V. CONCLUSION
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III. BULIMIA NERVOSA

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Avoidance of obesity
Recurrent, secretive binge-eating
Fear of not being able to stop eating
Awareness that eating pattern is abnormal
Depressed moods and self-deprecating thoughts
Temporary relief via avoidance of weight gain by
o
Fasting
o
Catharsis or diuresis
o
Self-induced vomiting
o
Exercise


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A. SIGNS AND SYMPTOMS

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Episodic binge eating that may occur as often as several times a
day.
Self-induced vomiting
Fluctuation of weight; the weight will usually stays within normal
range because of the use of diuretics, laxatives, vomiting, and
exercise.
Hyperactivity, peculiar eating habits or rituals, frequent weighing
Person always perceive herself with distorted body image

B. TREATMENT

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The primary goal of treatment is to reduce or eliminate binge
eating and purging behavior:
o Nutritional rehabilitation, psychological intervention, and
medication management strategies.
Establishing a pattern of regular, non binge meals.
Improvement of attitudes related to the eating disorder.
Encouragement of healthy but not excessive exercise.
Resolution of co-occurring conditions such as mood or anxiety
disorders.
Individual psychotherapy.
Group psychotherapy.
Bea, Phonse, Thea
OS 211

Eating disorders are potentially life threatening, resulting in death
for as many as 10% of those who develop them.
They can also cause considerably psychological distress and major
physical complications.
Important relationships are eroded as the eating disorder takes up
time and energy, brings about self absorption, and impairs self
esteem. Treatment should be initiated as quickly as possible,
focus upon immediate distress experienced by the individual, and
aim to help the patient and family become powerful enough to
overcome the eating disorder.
Make sure you are medically stable and consult a doctor.
Get support: a counselor and nutritionist (both trained eating
disorders specialist), and eating disorders support groups.
Try new ways of thinking:
o
Focus on solutions to your issues.
o
Focus on what is working.
o
Take responsibility for your choices.
o
Keep being honest.
o
Express your feelings safely.
o
Notice what is right and what is good in your world.
o
Treat yourself as if you are your best friend.
o
Confront ill attitudes and behaviors in yourself.
Try new behaviors:
o
Make a list of what you’re eating disorder does for you, and
come up with alternatives that deliver the same result.
o
When feeling down or uncomfortable, ask: “What would
you be doing if you felt better?” and then do it.
o
Talk about your mistakes and what you want to do
differently next time.
o
Explore new ways to communicate and set boundaries, you
will be taking: this would be taking care of yourself and self
esteem will benefit.
It was not too difficult to find information about this topic cause is
one of the biggest problems that overlays in our society and
around the world.
END OF TRANSCRIPTION
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